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SAN JOAQUIOCOUNTY ENVIRONMENTAL HEALTH L-PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />6 <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />�s „l <br />PHONE EIT. <br />aO z <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />J/� <br />FAX # <br />( ) <br />CITY ` <br />SITE ADDRESS % <br />Street Number <br />DlrecHon <br />Slreel Name <br />9T�F <br />CIN _I <br />Zip Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street ,Dumber <br />DATE: `7 . -'2 <br />Street Name <br />CITY <br />Date Service Completed (if already completed): <br />STATE ZIP <br />PHONE#1 <br />( ) <br />EXT. APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />t ) <br />EXT, <br />Amount Paid;' <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REOUESTOR <br />6 <br />CHECK If BILLING A00RESS <br />BUSINESS NAME <br />� r� s /� aw <br />7 <br />�o/ <br />�s „l <br />PHONE EIT. <br />aO z <br />HOME or MAILING ADDRESS t^ —�o - <br />f <br />/f e <br />J/� <br />FAX # <br />( ) <br />CITY ` <br />STATE ZIP P �� <br />BILLING ACKNOWLEDGEMENT: t, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application,an t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA n F ERAL WS. <br />n <br />APPLICANT'S SIGNATURE: "5' Q ✓ DATE: <br />I <br />PROPERTY/ BUSINESS OWNER El OPERATOR I MANAGER OTHER AUTHORIZED AGENT -{Q-C <br />If APPLICANTIS not the BILLING PARTY, proo of authorization to sign is requi ed Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provor <br />my representative. ^� r <br />TYPE OF SERVICE REQUESTED: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />ry <br />COMMENTS. <br />SANdo 2' Z <br />HFg4N�oO 0 <br />9T�F <br />ACCEPTED BY: e�. t <br />EMPLOYEE #: <br />DATE: `7 . -'2 <br />ASSIGNED TO: C�l A <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: a <br />PIE:?)�Ga, <br />Fee Amount: t2/0 CO <br />Amount Paid;' <br />Payment Date <br />-- <br />7 <br />Payment Type V <br />Invoice # <br />Check # <I-� r <br />Receivved, By: <br />J <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />ry <br />